Hydén and Hartelius in a recent monograph (1) described nerve cell abnormalities which they consider to be characteristic of mental disease. Their investigations were based on biopsies obtained during prefrontal leucotomy carried out in 11 psychotic patients, 10 of whom belonged to the schizophrenic group. The biopsies were investigated by means of the ultraviolet microscope and the results compared with brain material from normal patients fixed a few hours after death. Two types of abnormal nerve cells were found in the psychotic patients: one type is narrow and shrunken with corkscrew-shaped apical process and appears dark in the photographs in contrast to the other type which is swollen and appears light in the photographs. Both these cells lacked polynucleotides in their cell bodies and contained only a small amount of other protein substances, as shown by the ultraviolet absorption spectra.

Communicated mental illness or “folie à deux” in which the parent appears to have influenced the child is a frequently found disturbance in general practice and Child Guidance Clinics. The child is especially disposed to such a disturbance because he lives during the first years of his life in almost complete identification with the parents' psyche. In a healthy environment his growing consciousness will gradually resolve this identity, and thereby develop his ego and individuality. If, however, one or both parents suffer from mental illness this process is liable to be disturbed, and the child will remain fixated to the disordered psyche of the parent.

I am indebted to you for giving me this opportunity to put before you certain tentative conclusions at which I have arrived as a result of working at the problem of physiological instability on a group of 525 children between the ages of 6 and 14. Like so many investigations of this type, it began on a presumption that was not borne out by further experience, and because of this it caused me to revise certain views I held on the subject.

Brain and Strauss (1945) emphasize that a patient recovering from the immediate effects of rupture of a congenital intracranial aneurysm may show “some reduction of mental function, varying from impairment of memory and inability to concentrate to more serious disturbances.” They add, “The importance of these residual symptoms lies in the possibility that they may lead to faulty diagnosis if the patient is first seen some time after the leakage which produced them.” In view of the significance of this eventuality, the following case is of relevant interest. I saw the patient for the first time when the paranoid features were already the most prominent clinical manifestations of the case.

Out of 95 leucotomy cases of which the brains and clinical records have been collected at this laboratory, 45 were cases with post-operative survival of over 5 months, and more than 20 of these showed some degree of clinical improvement. Such numbers now make worth while an attempt to ascertain whether or not any attribute common to the lesions is a prerequisite to clinical improvement; whether or not the degree of improvement tends to vary with any qualitative or quantitative feature of the lesions; and whether or not any such relationship between lesions and improvement which is revealed holds good in equal degree for each of the main types of functional-psychosis. Over 20 of the same 45 cases had a recorded post-operative change of personality, so that relationship of post-operative personality change to the leucotomy lesions can conveniently be investigated in the same group of cases. Only some general findings concerning the personality change will, however, be touched on in the present paper.

In my student days, after the first world war, teachers and text-books still used the term dementia praecox. It was looked upon as a disease sui generis, and descriptions were entirely in terms of clear-cut asylum cases with the usual classification into simple, hebephrenic, katatonic and paranoid. There was no psychopathology worth noting, and no anticipation of the immense gap waiting to be explored between “normality” and complete mental breakdown. In effect this meant that there was no half-way house in diagnosis: it was either dementia praecox or nothing. The revolutionary change in diagnostic approach began with Bleuler's highly original conception of the disorder as a progressive splitting of the psyche, indicated by the name schizophrenia which he gave to it, and which now holds the field. Added to this there are the researches of the psycho-analytical schools (the Jungians in particular) which have succeeded in opening up a huge and fascinating borderland on the fringe of normality, with a corresponding enlargement of our notions of schizophrenic disorders.

This paper presents an example of the depersonalization syndrome as experienced and described by an intelligent patient. Considering the frequency of its occurrence, this syndrome has not been as often recognized nor as adequately described as would be expected. The syndrome was first described by Mayer-Gross (1935), later by Gordon (1936), Shorvon (1946, 1947) and Tayleur Stockings (1947). The psychopathology of depersonalization was given in analytical terms by Oberndorf (1935, 1936) and Feigenbaum (1937); Galdston has recently discussed this aspect (1947). As a symptom of organic brain disease, depersonalization offers an interesting field in the long-disputed question of body-mind relationship. Reidl (1942) described this symptom in a case of carbon monoxide poisoning, and Brock and Weisel (1942) discussed its occurrence in organic cerebral disease. Guttman and Maclay (1936) described the interesting relationship between mescaline intoxication and depersonalization. Cerebral anatomical localization was discussed in an anatomico-clinical study by Dide (1938).

The operation of transorbital leucotomy recently described in the Lancet by Freeman (1948) was originally devised and carried out by Fiamberti in 1937 very soon after Moniz had introduced the original operation of leucotomy. Meyer, Beck and McLardy (1947) have shown that degeneration of the central portion of the pars parvicellularis of the dorso-medial nucleus of the thalamus was correlated with a lesion involving areas 9, 10 and 46 in the middle frontal gyrus. The transorbital method might now be said to follow almost logically on the work being done at the Columbia Presbyterian Medical Center and at the Greystone State Hospital, New Jersey, by a team of 96 (!) collaborators. Brodmann areas 9 and 10 and in some cases part of area 46 of the cerebral cortex are removed by an open bone-flap operation. This work is still in its infancy, and is not yet published apart from a summary by Nolan Lewis (1948). The entire project is to be described in a volume, The Human Frontal Lobe, to be published at an early date.

Courville (1945) remarks that: “It was almost a medical habit in England on the part of physicians with literary leanings in the first half of the nineteenth century to write an essay on ‘water on the brain’.” It was not, however, until the experimental work of Dandy (1917) was published that a dynamic and scientific approach to the problem became possible. To this day no generally effective and applicable method of treatment has been devised. This is possibly due in part to the tendency to lump together a variety of conditions of different aetiology and pathology under the one heading. To emphasize this point it is perhaps useful to publish the following case, which clinically seemed to be one of simple hydrocephalus, but post-mortem examination of which showed that the symptoms had quite a different origin.

Although chess sets are usually to be found in the games cupboards of the male wards of a mental hospital, it is a rare sight to see two patients indulging in this game. Nevertheless, it may be a humiliating experience for any medical officer to challenge a patient to a match unless he is a fairly good player.

There are few studies relating electroencephalographic characters with mental deterioration. Romano and Engel (1) (2) made an EEG and clinical study of “delirium” which they defined as the “toxic-infective state or psychosis associated with somatic disease” which was accompanied by “fluctuation in the level of awareness” and “intellectual, emotional and motor regressive behaviour”; the group included cases of chronic and acute cardiac decompensation, chronic alcoholism, hypertensive states, and severe Addison's disease. These authors considered that the EEG changes could be graded into three main groups, in order of severity: firstly,” decrease in frequency,” with increase of slow 4–7 frequencies and normal blocking responses to visual attention; next, “disorganization,” with irregular slow 2–7 frequencies and poor blocking responses; and finally,” reorganization at a lower energy level,” with moderately high voltage slow 3–7 c./sec. activity, few or no normal frequencies, and absent blocking response to visual attention. This latter stage was, in some cases, found to be irreversible. Previously, Engel and Margolin (3) had published the results of an investigation into the effect of both oxygen and glucose-deprivation on the human electro-encephalogram. Both these conditions produced bursts of diffuse generalized 3–6 c./sec. activity which, in those cases with an acute onset, reverted to normal rhythms as clinical improvement occurred. However, 4 patients with chronic cerebral anoxaemia were examined (end-stages of chronic bronchitis with right-sided heart-failure) in whom the EEG abnormalities persisted; at an early stage, activity with a frequency of 5–6 c./sec. appeared, and still later the records became completely disorganized. There was one patient who ultimately recovered whose EEG showed a regular dominant alpha rhythm with a frequency of 7.5 to 8 c./sec. It had already been noticed that, in a few cases where the EEG had apparently returned to normal in prolonged anoxic and hypoglycaemic cases, there yet remained some degree of intellectual deficit on psychological testing. Hill (4) had observed that a type of EEG with a slower dominant alpha-rhythm than the normal 8–13 c./sec. (i.e. a rhythm at 6–8c./sec.) was frequently associated with mental deterioration. An investigation was accordingly instituted to determine to what degree mental deterioration and slowing of the dominant rhythm in the post-central areas (alpha-rhythm) were associated.